- Season 11, episode 21,
McDreamy says goodnight. Let's watch it together. Beep-wop. (engine revving) (vehicles slamming) (brakes squealing) Okay, first mistake he's making here, you need to call for help. (record scratching) (light, whimsical music) - My phone's not working. - Because there's very limited things you can do on the road without any tools. You you need to call for help
and get emergency transport to get them to a hospital where they could actually
be taken care of. - Hey, I can't open the door. - Winnie, Winnie. - Ma'am. - Winnie. - Hey, hey, what's your name? - Sarah. - Sarah, who's Winnie? - My daughter. - Hey, you're Winnie? - I think I'm dead. - Well, you're not dead. I can feel a purse in your wrist, and you can't be dead if
your heart's still beating. See, I'm a doctor and I'm telling you. You ever wanna know if you're dead? Feel your pulse. - Maybe that's a little dark thing to say to a child. - [Derek] Listen, I'm gonna get you out. It's gonna hurt a lot. - I don't know if it's
shock, or if it's that my leg hurts so badly that
I almost can't recognize it. It almost feels normal, so
maybe it won't be so bad getting me out. - Sounds like you dislocated your hip. - How does he know that? He's just feeling around
over there and he's like, yeah, dislocated the hip. Yeah, no special tests, eh. - I'm gonna get you out of this car. - Okay.
- Down on the ground, and then pop it back into the socket. - How does he know it's dislocated versus like a full-on
fracture that's displaced? He just has miraculous
hands that have x-ray field. (Sarah screams) - The dislocation has cut off
the blood supply to your leg. If I don't do something,
you could lose it. - So that's the only time
you would do a reduction in the field like this. If you see that the vascular
supply, meaning the blood flow that is going to the
lower limb is obstructed, because of the dislocation. That can happen. In this case, yeah, he
should try and put it back so that he restores blood flow. Otherwise, literally the rest of her leg starts dying in necrosing. (bone cracks)
(Sarah yells) Whenever you do a reduction
of dislocation, initially, worst pain ever afterwards,
it feels kind of good. - Help, help. - Does it hurt anywhere? - No. I'm not supposed to be here, I have to go. - Listen to me, you're probably in shock. Okay? You got a lot of adrenaline
going to your head right now. There might be something wrong with you that you don't feel right now. So I need you to slow down. - That is very accurate. In fact, paramedics are
trained to tell folks who've been in car accidents to calm down because it's very easy to
say, I'm fine, I'm fine. I don't need to go get emergency care because you are on adrenaline. You don't feel your internal injuries and you could potentially be bleeding out. And it's also so important to know the mechanism of the injury. Like the fact that this was
such a high speed car accident already puts her at a
risk of severe fractures. Vertebral fractures, internal bleeding. - I just need to undo a button so I can look at your stomach. - He's going to see it like bruising or he's going to see a giant
laceration with intestines. - Got a hand it to you, you got it, go home and have yourself
a drink, you earned it. (soft music) (phone buzzing) - Oh, and that's why you don't stop in the middle of the road. - Blunt force trauma to the head, chest and abdomen, persistent hypotension after two liters of saline. Pulse is thready at 130. - Okay so that's important information. So after giving him two liters of fluid to try and bump up his blood pressure, it's still persistently low, which means that he's in a dangerous spot. Ideally they want to give him more fluids, more blood products if that fails, you have to start them on pressors in order to keep his blood pressure up, to give sufficient blood
flow to the vital organs. Also, they sent his blood. His pulse is 130, which means
that it's fast tachycardic. Reason being is when the
blood pressure's low. The heart tries to
compensate by beating faster in order to like fake
increase the pressure. - [Doctor] Can you hear me? - Yes, yes. I can hear you. Loss of verbal skills, possible bleeding in the brain. - [Doctor] His pupils
are equal and reactive. - Good sign. Still should get a CT. - He's got a flail chest in the right. I need a 36 french tube now. - Alright so they said
he has a flail chest. That means he has
significant rib fractures, like complete fractures on one side, maybe even a pneumothorax, because what happens is when
you have a complete disconnect of your chest like that, your breathing happens
paradoxically on the side where you have your injury. - This is gonna to hurt,
but we have to do it. (incision sounds) (deep breathe) - They're basically putting
in a chest tube to drain it. His chest of blood because
he's bleeding internally, which will allow his lungs
and potentially his heart to expand when they are
beating and filling up with either air or blood respectively. You also, sometimes if
you have a pneumothorax, a collapsed lung, when
you equalize the pressure, you allow the lung to expand as well. - He fixed our ride. He helped Charlie. And then he put all of us
inside his back and he saved us. - He saved you? - All of us. He's a doctor. - He's a doctor. - So you should treat him differently than you would any other patient what. - We've got you, and
it's all gonna be okay. - This isn't right. You should have taken me to get a head CT. - Anytime you have blunt
force trauma to the head with a serious accident
again, mechanism of injury. Semi-truck hitting you
at a fast rate of speed. Get CT's. We over-order CT's in
emergency rooms for things that don't really matter yet when people have a really high-speed car accident, people are like should we get a head CT? Yes. You need to figure out if
there's bleeding internally. Because you're management
completely changes. - We have to work fast people. - I'm stable guys, I'm stable. Take me to get the head CT. - The way you decide if someone's stable is you look at their vitals. If his blood pressure's not tanking, you know that the patient is stable enough to go get a head CT. And if there's bleeding in the brain, you want to save the brain
because without the brain, there is no body. - He's got a great tooth blown apart. - Meredith would leave it. - Let's leave it. - At the four quadrants. - And she'd double-check
the retrohepatic space. - The retrohepatic space is
a very commonly known one that you learned in
your surgery rotations, where you can lose a lot of
blood and not even know it. - He is still hypertensive. - Heart is intact. He's not bleeding in his chest, this makes no sense. - I'm missing something. - Start on TEE. - Not that. That's not what you're missing. - A TEE is transesophageal echocardiogram where essentially you
put an ultrasound probe into the esophagus in order
to better visualize the heart. - You got a headlock check. Check his pupils. - His right pupil is blown. - Anisocoria can happen
when you are having bleeding into the brain. - Pave to neurosurgery,
right freaking now. - The hell have you people screwed up now. - Us, you're on call for trauma. What took you so long? - Who the hell are you? - Your response to him was
supposed to be 20 minutes. - It wouldn't have made a difference. - If you guys had ordered a head CT, you would call me sooner. - You were supposed to
be here in 20 minutes, not an hour and a half. We have a chance. He
had a freaking chance. Get him an IOR. - What? - That type of blame game can
happen in a hospital setting where there's big egos. I mean, obviously both are in the wrong. Does it matter who's more wrong? No. The only thing that should
matter is the patient and try to do the best
that they could now. - It's too late. - The call to not get a
head CT was a bad call. - We're not a trauma
center or a teaching-- - You did the best you could. - I mean a head CT. Like if they made a mistake
with some kind of protocol, I get it because they're
not a trauma center. That makes sense. But not getting a head CT
is just incredible to me. Like that's the first thing
you would do in a car accident of that nature. Remember the mechanism of injury there, in fact, there's like a
Canadian head CT protocol. And one of the points is
the mechanism of injury. And it's like, if it's a
high speed accident, boom, you get the head CT. Like I still even remember
that from med school. I also don't quite understand
how they were certain that he had abdominal bleeding over, like how do they know he wasn't bleeding into his brain versus his abdomen? Like it seemed like they just guessed that because if you're doing anything, your pants scanning the patient, you're scanning the head. You're scanning the lungs. I mean the chest and the abdomen, you're doing it all at once. - Mrs. Shepherd. There's some things you need to know. Some things we need to discuss. Difficult things. - I'm a doctor. You've waited the
requisite number of hours and now you can officially
declare him dead. So yes, you needs a bed. And those must be the papers. - Essentially, the ICU wants
to clear the patient out if there's no improvements being made. And while that is part of what goes into medical decision-making obviously when it comes to triage, but also it's in the
patient's best interest to not be further tortured if there is no potential
chance of recovery. - I'd stop all curative intervention. Discontinue all routine monitoring, remove all the catheters,
drains, and tubes and any and all treatments
that might provide comfort to the patient. Terminate all life-sustaining measures. - Well see that's not exactly true. When we fill out a POLST form, we actually can put orders in that would put a patient on comfort care. So we would put orders in to make sure the patient is comfortable. Giving them high sedation, giving them pain control, mucus control, cough control, hiccup control. There's all sorts of things
that we need to think about for a patient who's at
the end of their lives. And we do that with our
comfort care order set. When we choose to say that
aggressively treating someone causes them more harm than actual benefit. We're not saying discontinue everything. We're discontinuing certain things that we feel like harm the patient. And we continue certain
things or begin things that we think would benefit the patient, meaning that the goal is no longer to make the patient live longer, but to make the patient as
comfortable as possible. Oh no McDreamy is going to die. (somber music) One of the mistakes
I've seen residents make is when they are putting
a patient on comfort care and they're discontinuing the ventilator and all these things. They forget to turn off the alarms because remember the
alarms just notify you when a patient's crashing
and it's very discomforting for a family to watch their
loved one go peacefully. But then the alarms going off like crazy that the patient's dying. So you've got to turn those off as well. (alarm beeping) And they didn't turn off the alarms. McDreamy. One of the hardest
conversations in medicine is the end of life conversation. And this is supposed to happen, not just with someone
who's terminally ill, someone who's just been in a car accident. It's supposed to happen with
your primary care doctor. So you can have a plan
because without a plan, so many things can go wrong. What's to happen? What are their wishes? Who's going to be the power of attorney? What do they want from their
care, medically speaking. And an important aspect of
that is understanding that there's never a sure-fire correct answer because patients a lot of times
will ask of me as a doctor. Should I do this? Should I take them off life support? Do they have a chance to get better? A lot of times you have to
give the most accurate answer, but it's not a hundred
percent accurate answer. A lot of folks are not
comfortable with that. But the unfortunate
reality is that's life. Every decision cannot
be a hundred percent. And ultimately it's your choice that has to be decided upon. Based on the wishes of
what the patient wanted. Here's the difference between
real doctors and TV doctors, click here to check that out. Great video I share some
epic patient stories and as always, stay happy and healthy. Unlike McDreamy. (upbeat music)
I liked the old title :(
Doctor mike can you tell me somthing is on my wrist and it’s not hurt burning anything dealing with hurting it’s a medium circle and it’s worrying me